Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Saturday, October 07, 2006

Taking Trust

When Tiger Woods addresses the ball, he's focused like a cat that heard a rustle in the leaves. He takes a few practice swings, moves up to position, adjusts his feet, steadies his shoulders, locks his eyes onto the target. He waits until there's absolute silence, brings his breathing under control, funnels all his energy into the impending swing; takes the club back, and explodes in an immensely balletic movement. It stops the breath of an onlooker, ripples the air in a wave that goes forever. Making a surgical incision is nothing like that.

But it almost is; and it should be.

Having held the patient's hand as she goes to sleep, having whispered "We'll take good care of you" as his eyes flutter to stillness, the personal remnant is still very much there as I begin, even as the person is covered in sterile green paper, exposing only the belly. It's the midline incision, especially the one in the upper belly, from breastbone to navel, that's the most intimate. To me, anyway. It's so direct, so frontal, so against the rules of personal space. Maybe even sexual. Because it's right into the middle of who she is -- the thrust aimed where anyone -- even a friend -- would hunch away to protect himself; yet, here I am, purposefully slicing deep into his core, willing and able, allowed, invited, trusted, observed. Going through the skin, the initial cut -- that's the cataclysm, the breaking of the barrier, the crossing of the line. It's the leap of her faith, the breaching of the wall, the stepping into space. Within moments, it's routine, nearly generic: his insides look like mine, yours. Been there. But the primal cut, the slice through that first and last line of protection, his skin, her freckles, the fine little hairs, the vulnerable innocence: I feel the intrusion, the awfulness, the promise made and broken simultaneously. After all these years, I never lost the wonder, the momentary look inward, the catch of breath, the faint crescendo of pulse.Primum non nocere!

These young guys: they like to cut only part-way through the dermis and put down their knife, finish off the skin with electrocautery; cook their way through the fat, smoke rising, stops and starts, pissily branding each little bleeder. I think they don't know -- really know -- what an incision is. No wonder their love for it is less personal, more abstract, more easily stolen. Take the knife in your hand, sister, and don't put it down. Watch me: take a clean and deep stroke through skin, fat, right down to fascia.. Have the courage of your convictions; make good on your promise and carry that same cut through the white line, the linea alba; let's see that little layer of fat that covers the peritoneum, let it show on the first swing. The patient deserves your best shot, your most bold. Honor your covenant to address him with all of your conviction and purpose. Swaddle the wound with pads, the bleeding isn't much and can wait.

I will reach in gently and caress the liver, the stomach and spleen. Slide over the top, into the recesses, curl the fingers enough to sense the texture, the fullness. The bowels move away and under, and over the top as I direct my hand. I can describe your kidneys now, I've circled the top of your rectum, held your uterus, measured your ovaries between my fingers. Part of you is gone at the moment, but I'm here, I know you now. You trusted and let me in, you opened your belly to me, and I entered with force. I'll stay until it's right. It's what I must do. You think you'll never touch me so intimately as I've touched you. But you have. You have.

48 comments:

Thank you. I have always felt that surgery is, or should be, a sacrament. That is one of the reasons that harmony in the OR is important to me. If the CRNA and the circulator want to fight, they can do it somewhere else. The patient deserves our best.

Sacrament is just the way to put it. We dip our hands into the holiest of waters. Which is not to say there can't be lightness and fun in the OR: sheer joy, or jocularity to break the tension. That, it seems to me, doesn't disrespect the nature of the relationship. But the solemnity of the duty is always there, or should be.

anonymous: Of course you're freaked out; everyone is, or they aren't thinking. But it's amazingly safe nowadays; anesthesia equipment is so sophisticated there's almost no way anything can go wrong. I used to say you're never safer than when you're having surgery: things are known about your important functions at all times, in ways they aren't otherwise. I think you'll be fine!

oh my God! this was s o poetic! you have shown me a side of a physician that i have never seen before. and ive been around the medical profession all my life. my mother was an xray tech for over 35 years. now i am a medical assistant, even though i work in the fron office at my job. but this was awesome, truely! i am so moved that you shared this. i hope there are others who feel this way too.again, than you!

I discovered medblogs after undergoing an open chole. It was the first time I had ever had surgery and I became fascinated by the whole process. I purchased your book after I saw it on “Cut to Cure”. I wanted to know what kind of person becomes a surgeon; what he/she feels when making that initial cut, how they handle the responsibility and pressure of their job. I enjoyed the book but this entry was right on point. I am kinda glad you waited a while to address this on your blog. It gave us a chance to get to know you first. It was way too intimate to reveal to strangers.

Dr. Schwab, I read this post on Saturday, got freaked out, and came back to it today to see if I could try to open my mind to it. I had this theory that perhaps trying to understand how a surgeon thinks will help me.

I had surgery for ovarian cancer six months ago. I expected a BSO/TAH; I did not expect to wake up with 48 cm of perfectly functional colon removed and a colostomy, but that’s what I got. A few months into chemo the midline incision "dehisced" and drained pus from a fistula formed by the stapled end of the rectal stump, which never healed properly. It drained for six weeks. By now the midline has drawn down into the belly and has a hideous 2-inch oval scar in the center, with a pronounced bulge around the stoma. Fungal infection and acid from stool leakage has turned the skin into a red angry mess. Before someone says it, yes, I am grateful to be alive. In fact, every time I look at my gut (that’s six times a day with a transverse colostomy), I say to it, "this is better than being dead."

I am not shallow. I am just an average-looking single 44-year-old with a mutilated abdomen who has to handle her own feces all day because a surgeon whom I had never met before was called into the OR after my abdomen was opened and decided that the risk of future bowel obstruction outweighed whatever objections I might have raised had I been conscious and consulted. Subsequent to surgery and five cycles of chemo, two separate BE examinations of the rectal stump and two separate CT scans show no pelvic masses, no definite signs of metastasis and no stricture or obstruction. That’s the good news, and it’s very good news indeed. Except for the fact that insurance won’t cover a “takedown” of the colostomy because it’s “elective.” And the (new) surgeon doesn’t think I’d be happy with a takedown anyway, because so much bowel is missing that I will have chronic diarrhea for the rest of my life, and it might be easier on my body in the long run to handle that with a colostomy. He says.

Now I have to decide whether to continue with chemo or to undergo a second-look laparotomy. The internist is willing to continue chemo; the surgeon is willing to operate; there is no "right" answer, they say; the decision is mine. I lost one-fifth of my body weight and all my hair on chemo, it gave me permanent nerve damage in my feet, it gave me anemia and electrolyte problems serious enough to require hospitalization. I know chemo. It wasn’t until I read your post that I really realized why I refuse to consent to further surgery unless they tell me I’ll die immediately without it. Why I have agreed with open eyes to take more of the punishment that I know chemo has in store for me.

Your writing is beautiful. I tried to imagine my surgeon writing like that, thinking like that, if only to convince myself that the covenant of reciprocal trust can be restablished, and I can’t. I have no way of knowing whether this is “fair” to the surgeon who cut out half my colon or not. I have no way of knowing whether it’s “fair” to my new surgeon. I have no way of knowing whether it’s “fair” to myself. It’s just true. If surgery is a sacrament, then I am excommunicate.

anonymous: what a difficult situation, graphically and well told. I wish I could offer something meaningful, beyond sympathy. It's hard to second guess an inta operative decision like the one that was made in your case; most especially without having been there or knowing lots of detail. But I'd say a couple of things: unless you have really horrible insurance, a colostomy takedown certainly should be covered. If the prescribed appeal process doesn't work, I'd even consider having a lawyer familiar with such things look at the fine print in your contract. Second: most people have pretty close to normal bowel function with half a colon or less. I've had several patients in whom it was necessary to take the entire colon except for the rectum, who had good function and control with their small intestine hooked to their rectum. If the management of your colostomy is really not tolerable, it's something to consider. Mainly, I'm sorry to hear your sad story. None of us surgeons can say that every decision we made -- especially those made without advance planning -- have worked out perfectly.

What an absolutely stunning piece, Dr. S! Lyrical. Deeply moving. It is gratifying on an intimate level to know that a surgeon can feel this way about the patients in their care; I wish all surgeons did. Thank you for sharing such a profoundly personal perspective. You have brought me to tears, and given me hope.

Dr. Schwab, thank you for your kind response to me. My own surgeon is so instantly defensive about the subject that it does me more psychological harm than good to discuss it with him, and he wasn't even involved in the original surgery. I should say that it has never even crossed my mind to think that I am a victim of malpractice; even at my worst moments of self-pity I cannot bring myself to think that a bad decision is anything other than just a bad decision, and we've all made them. That said, I believe that the surgeon responsible for this was too aggressive, too unwilling to consider medical-chemo alternatives to surgery, a little arrogant about his ability to successfully resect unprepared bowel, and, from what I learned in his one and only 5-minute visit to my bedside post-op, shockingly blase about the psychological burdens of this surgical procedure. I am sure that most of the time his surgical aggressiveness is warranted and successful. It's just "life's a bitch" for for me that damn near everything that could have gone wrong did, and for what in 20/20 hindsight appears very little reason. He is not, of course, around to help me clean up the mess or learn to live with it. I understand that that "isn't his job." I can imagine how painful it must be to perform an operation you know will traumatize the patient, and that you fear may end up with terrible complications. But the fact is, I got more sympathy and respect in the comment section of a blog of a doctor who doesn't know me, didn't do it, and was just there when I surfed by than I ever got from my own surgeon. I suspect it isn't any fun to follow up with your mutilated patients. Perhaps someday I will develop some sympathy for that. It probably won't be any time soon.

May I say, just for the record, that WOC nurses are second only to Onc nurses in hierarchy of angels? And even though he's a surgeon, Dr. Schwab is fit to be in their company?

Thank you for being willing to hear it all. Your patients are so very lucky.

Yes, absolutely. As a med student and (hopefully) future surgeon, and having done only a few proper incisions myself, I think you have captured the intimacy completely. I thought I only felt that way because I am so NEW at this; it's fantastic to see that experienced surgeons still feel this.

I spent last month with a young staff who let me do a great deal, and it was fantastic. But I also assisted at a few surgeries with a senior surgeon, and watching him work was indescribable. He was unhurried and yet, everything happened much faster than I would have thought possible.

newdoc: I love harking back to the times when it was all so new. And remembering how watching good surgery made me feel: awed; and unsure I'd ever be able to do it that well. That's what I tried to capture, along with the progress to actually getting to the point of doing it, in my (plug, plug) book.

To the extent that it is disturbing, clearly I failed in my attempt in communicating. Perhaps I should have chosen my words differently. My respect for the body of the patient, my awe that I am allowed this amazing thing, the contract that it implies between me and my patient -- those are the things I had in mind. Perhaps I overestimated my ability as a writer. Maybe I got carried away. But doing surgery is a mystical thing to me in some ways; I wanted to convey that. For some, I failed. I might add that the only patients of mine that nearly died (or did die) in surgery were ones that came to the OR with unsalvageable situations. I won't claim perfection, nor gifts beyone those of any other surgeons. But I did approach every operation with the belief -- formed in part by my respect for what I was about to do -- that I owed the patient my very best at all times: the best preparation, the best thoughts about what I was going to do. If I were to be trusted, I had to be worthy of it. Maybe I should have stuck to operating and not trying to describe it.

I read the discussion over at the Dino site and I have to say, Dr. Schwab, that you did not fail as a writer.

Invasive, violating, intimate, healing, helping - health care tends to cross all these boundaries in ways that we usually don't think about or acknowledge.

After experiencing a medical injury, I felt violated. It didn't help when I had to have surgery to fix the damage. Especially since no one was talking to me. I felt like a pariah, which unfortunately is pretty typical for people in these types of situations.

There was no way to convey the sense of outrage. No one would ever have understood it.

Dr. Schwab, you captured all the ambivalence. For a writer, that's a real feat.

A beautifully written post Dr S, but I too can see why anyone with a traumatic surgical experience would find it disturbing, unsettling. Exactly because surgery is an intimate experience - and requires trust. The violation of the initmacy of surgery on the core of one's body is horrific, and my condolances to those who do go through this... and who wake up every morning reminded of it. As Docs, we need, nay, we must be ever concious of the sensitivity of the risks attached to any surgery, and of fully informing the patient about everything, all along the way.

I too was wowed by this, especially the ending. Sid Schwab, you have touched my emotions, even more so than as Anysurgeon you may have touched my organs. I have entrusted you, whom I may have met only once or twice before, with my life, and in that moment of the first cut there are just the two of us, even though I have no awareness of it. You are right - what could be more intimate? and yes, maybe sacrament is not too strong a word to use.I like to think that you have spoken for the many compassionate surgeons who, even if they share your gift of words, may not have the time to use it.Thank you.

Your post is stunningly beautiful and most importantly, respectful of the care required to embark on the enormous task of cutting into a living human being, doing your work, closing up in a way that minimizes the evidence you were ever there, and see the patient through recovery.

I sympathize with those who have been victims of medical malpractice or who feel violated in some way from those in whom they placed their trust. Especially disturbing is the story posted here which bordered on a violation of informed consent; whether or not that was the case is not as much the point as living with the aftermath. But those who think this post accurately describes a violation probably are keying into out-of-context descriptions of holding a uterus or ovary; I seriously doubt you'd get the same reaction from a post describing the slick, spongy feel of a healthy liver, for example. In that sense, this is more of a problem of psychology than bad wordsmithing.

Just as not everyone is able to handle working in medicine, be it a doctor, nurse--anyone on the front lines of health care who come face to face with death, disease, abscesses shooting pus across your shoulder during an I&D, shit and piss on the sheets, bilious, green vomit (yes, I'm being intentionally graphic)--not everyone will be able to read a post such as this and see the beauty, awe and respect. They will never understand. I could have a lenghy conversation of how incredible various molecular mechanisms of cancers can be, the way they evade the body's defenses, using normal, benign processes as hideous tools of destruction. I'd never think to have that conversation with a patient, because without the context, it sounds as though I'd enjoy seeing another cancer, whereas the real motivation would be fearful awe and respect.

The difference is that you write for yourself with your audience in mind, not modulate/second guess your writings with what people might think. If they don't like it or understand it in spite of your best efforts, the loss is theirs. Bring things with honesty from your perspective of such a long history of service to medicine, surgery and humanity, and you'll find there will be just as many people willing to read as there will ever be.

some of the comments expressed hope that surgery is taught like this. i have fairly recently qualified as a general surgeon and in my experience surgery is most definitely not taught like this. in fact the brutal way that surgery is taught inspired me to attempt to be an exception to the rule and rather try to impart my love for surgery to the juniors that work with me. i always chant my mantra,'love surgery, not the surgeon.' this is because the surgeon is more often than not such a megalomaniac prick that it would not be possible to like, nevermind love him. this is the first time i've seen someone express humble appreciation to his patients. it is after all they that afford us the priveledge of practicing our proffession. thank you for sharing this post.

Wow, you've put into words what I was unable to describe. I've always thought surgery had a romantic side to it. A surgeon gets to go where even the individuals themselves won't ever get to. Cut into a sealed envelope that is the person. I had to observe surgeries in college as part of my degree requirements and was always hugely jealous.

I'm glad to know I'm not the only one that think surgery is a beautiful thing, blood, guts and all.

I just reread this and will read it again and will be recommending it on my blog. I AM STILL in awe of this post. So eloquently written. Intimate,sacred and amazing! When I get a little more blog savey I am definitely linking to you!

I wanted to tell you how much I liked your post about the intimacy of a surgeon-patient relationship. 16 years ago (I was a young adult) I sustained a severe brain injury in a car accident and was in a coma. I had a ventriculostomy, and my husband says a feeding tube was put into my stomach some time later. When I woke up everyone thought I would be paralyzed. My trauma surgeon took me for a walk (I remember how sleepy I felt so I didn't want to get out of bed for anyone but him), and now its as if I was never injured. I still get a bit dizzy once and a while if I turn fast, but I've returned to college and am earning a 3.8 GPA and I'm always running after my six children. I dedicate every class I take in college to my trauma surgeon and I write him about once every week or two to give him an update on my grades. I'm so grateful for his kindness as well as his skill. I know how busy he is with the work he does that I hold in such awe, and the last thing I would want to do is bother him with so many letters. However, after reading about how much honor you give your patients I feel less bothersome. Thank you so much.

What more can I say than WOW! I thoroughly enjoy your blog posts! I am a med/surg RN and I take care of a lot of abdominal surgeries. Your posts always hit home, enlighten me, as well as remind me that the surgeons I work with are truely artists. You write with such poetic yet precise steps- it reminds me of how I talk my patients thorugh procedures such as NG placement- Keep up the great work- both the caring and the writing you are very gifted!

As a new surgeon, I find that my job is filled with hassles and intrusions that I never anticipated. Insurance companies calling, discharge planning to set up, paperwork always looming, the phone endlessly ringing. The OR always was a haven, even during residency, but now even more so. The few times a week that I get to settle into a case, focus in on the few square centimeters in front of me, and just operate....they are the moments that keep me going. Medicine is special, but surgery is phenomenal. Surgeons are different, thank goodness for that.

Dr. Scwab, what mixed emotions I have had reading this post and its comments. Your own personal experience was beautiful. Intimate, personal, like you said - almost sexual. After all, the intercourse we experience with procreation is not nearly as invasive as what a surgeon does when they come into our bodies.

However, having experienced the "rape" type surgery as well as the "lover" type surgery... it leaves me with a sadness that the brilliant surgeon who probably saved my knee function and gave me the last 20 years of a relatively normal life, was also the kind of surgeon that did not consider the mental welfare of the patient, but rather saw the successful result of his surgery as the end all of whatever means he used to an end.

It also makes me wonder how my current surgeon rates on this scale. I do not know if he holds the reverence of the body that you have held for your patience, but I think he might - at least to an extent... when consulting for this last surgery, he told me he had been thinking of this surgery (mine) literally for months, which would indicate to me that he has proper reverence and concern for me (or at least my knee). He also had another experienced surgeon who he works with come in and work with him during the procedure. This also would give me reason to trust him.

I wonder if I will ever get over my sense of paranoia concerning my surgeons. It makes a stressful situation much worse when you feel a lack of trust. How I wish I could be certain he felt as you do!

As a 27-year-old chick who's had nine surgeries for a plethora of medical issues (only two of which were deemed "delicate operations"), it's incredibly comforting to see the philosophical, virtually spiritual experience for the person on the other end of the scalpel that slices into my prone body. My first surgery was at age 3, so I never correlated fear with medical procedures. Thankfully, I've only had one surgical experience that was negative- and I have a feeling it's because most of the doctors I've chosen (after being thoroughly vetted) shared your same passion and respect for the human aspect of your particular niche in the health industry.

Thank you for your blog. Not only is it a great resource for patients who wish to supplement their education for an impending specific operation, but also introduces a certain element that's so often missing in a clinical setting: heart and soul.

OK-- now I might have to buy your book! Your ongoing sense of awe, each time you "entered" the patient's inner realm--is wonderful. Thank you for sharing your thoughts. As a RN I loved the OR though I did not make a career of it (in nursing) I did have a brief stint. It is my opinion that general surgeons are extraordinary in many ways--I have been privileged to work with several(good ones)and their 'grace under pressure' and tireless work ethic inspired. But not many of them can write!DD

About Me

I'm a mostly retired general surgeon. With my surgical blog, my intention is to inform, entertain, and possibly educate the reader about surgery, and about the life and loves of a surgeon: this one, anyway. Don't know what I'm thinking, doing a political blog, too.
In an amazing coincidence, I've also written a book, "Cutting Remarks; Insights and Recollections of a Surgeon." It's about my surgical training in San Francisco in the 1970s, aimed at the lay reader with the goal of entertaining with good stories, informing with understandable details of surgical anatomy, procedures, and diseases. Knowing you, I bet you'd enjoy it. In fact, if you like Surgeonsblog, you'll absolutely love the book!

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.